Condom-use decision making among pre-exposure prophylaxis (PrEP) users in a pharmacy-delivered PrEP project in South Africa: Qualitative insights from PPrEPP-SA

Background Community pharmacies increasingly serve as access points for HIV pre-exposure prophylaxis (PrEP) in South Africa and understanding how PrEP users in these settings make decisions about condom-use is essential to inform effective combination prevention strategies. This study explored condom-use decision-making among PrEP users accessing pharmacy-delivered services in South Africa. Methods This qualitative study formed part of the midline evaluation of the PPrEPP-SA project. In-depth interviews were conducted between March and May 2024. Interviews explored participants’ understanding of PrEP, sexual behaviours, perceptions of HIV/STI risk, and experiences with prevention methods. Audio-recorded interviews were transcribed verbatim and analysed thematically using Braun and Clarke’s inductive approach. Results 69 PrEP users aged 18–59 years were recruited from 10 community pharmacies across Gauteng and the Western Cape. Participants demonstrated varied and often negotiated condom-use practices while on PrEP. While most understood PrEP as effective for HIV prevention, some held misconceptions regarding its ability to prevent STIs, contributing to reduced condom-use. Decisions to forego condoms were linked to trust in partners, relationship stability, cohabitation, and preferences for condomless physical intimacy. Condom-use was more likely in casual partnerships or when partner HIV status was unknown. Participants also expressed a strong preference for purchased condoms over free public-sector condoms, citing concerns about quality and durability. Conclusion Condom-use among pharmacy-based PrEP users is context-dependent, shaped by relationships, risk perceptions, and understandings of PrEP. In South Africa, pharmacy-delivered PrEP programmes provide a critical opportunity to reinforce dual prevention messaging, address misconceptions, and improve access to acceptable, high-quality condoms as part of comprehensive HIV and sexual health prevention.